When compared with beclomethasone, theophylline was linked to 14% more central nervous system adverse effects (P<.001) and 17% more gastrointestinal disturbances (P<.001). Although beclomethasone induced more oral candidiasis compared with theophylline (8.9% vs 2.4%; P<.001), the incidence of this infection can be reduced by using a spacer.
Long-term systemic effects
The potential long-term adverse systemic effects of inhaled corticosteroids on growth, bone metabolism, and pituitary-adrenal function call for longer-term studies.4 A systematic review of 15 trials reported that the protective effect of leukotriene receptor antagonists is inferior to inhaled corticosteroids for adults (relative risk [RR]=1.71; 95% CI, 1.40–2.09); however, evidence is insufficient to extrapolate this to children.5
Beta-agonists
Evidence does not support use of long-acting beta-agonists as monotherapy or in combination with other medications for children with mild persistent asthma. Although 1 study showed an improvement in lung function for children taking budesonide plus formoterol compared with budesonide alone, the rate of severe exacerbations was lower for those taking budesonide alone (62% decrease vs 55.8% decrease; P=.001). Both groups had a 32% decrease in the number of rescue inhalations per day when compared with placebo (P=.0008).6
Recommendations from others
Recommendations are listed in the TABLE.1,7,8 Unlike the NAEPP and GINA asthma guidelines, the BTS/SIGN asthma guidelines define no objective measurement or staging classification to diagnose asthma among children. Diagnosis is determined by a child’s response to medication.8 Independent of any daily controller medication use, all children should have a short acting bronchodilator on hand in case of an acute attack.1,8
TABLE
Recommendations for treating mild persistent asthma
| GUIDELINE | DAILY CONTROLLER MEDICATION | ALTERNATIVE TREATMENT |
|---|---|---|
| National Asthma Education and Prevention Program (NAEPP)1 | Low-dose inhaled corticosteroids | Children <5: cromolyn, LTRAs Children >5: cromolyn, LTRAs, nedocromil, sustained release theophylline |
| Global initiative for asthma (GINA)7 | low-dose inhaled corticosteroids | All children: sustained released theophylline, Cromone, LTRAs |
| British Thoracic Society/Scottish intercollegiate Guidelines network (BTS/SIGN)8 | Inhaled steroids | All children: LTRAs, theophylline Children >5: cromones, nedocromil |
| LRTA leukotriene receptor antagonists. | ||
| Sources: NAEPP J Allergy Clin Immunol 20021; GINA Guidelines and Resources 20057 and BTS/SIGN, Thorax 2003.8 | ||